NGS WV Self-Administered Drugs and Biologicals Excluded from Coverage

Article for Self-Administered Drugs and Biologicals Excluded from Coverage - Medical Policy Article (A47528)

Contractor Information

Contractor Name

National Government Services, Inc.

Contractor Number

00453

Contractor Type

Article Information

Article ID Number

A47528

Article Type

SAD Exclusion Article

Key Article

Yes

Article Title

Self-Administered Drugs and Biologicals Excluded from Coverage - Medical Policy Article

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association.© 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Primary Geographic Jurisdiction

West Virginia

Secondary Geographic Jurisdiction

West Virginia

Original Article Effective Date

07/01/2008

Article Revision Effective Date

07/01/2008

Article Text

The table below lists drugs that are not covered by Medicare, the effective date of non-coverage, and the rationale. (Please see "Process for Determining Self-Administered Drug Exclusions – Medical Policy Article"). The column, "Brand Names," provides one or more examples but not all. Information about drugs not separately reimbursed or not covered for reasons other than "usually self-administered," is found in other carrier and fiscal intermediary publications and sites.

In the interest of consistent Medicare coverage, the National Government Services fiscal intermediary will follow the coverage decision for self-administered drugs as determined by the carrier in each respective state. HCPCS codes for the same drugs that apply only to providers that bill the fiscal intermediary (e.g., HCPCS codes used for drugs billable under the Outpatient Prospective Payment System [OPPS]) are included when applicable.

Coverage Topic

Outpatient Hospital Services
Prescription Drugs

Coding Information

No Coding Information has been entered in this section of the article.

Coding Table Information

CPT/HCPCS Codes - Table Format

Code	Descriptor Generic Name	Descriptor Brand Name	Exclusion Effective Date	Exclusion End Date	Comments
J0135	INJECTION, ADALIMUMAB, 20 MG	Injection, Adalimumab, 20 mg, Humira	04/15/2003	N/A	Rationale for Determination Subcutaneous injection frequently for a prolonged period of time..
J0270	INJECTION, ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED)	Alprostadil, Caverjet, Edex®	12/01/2002	N/A	Rationale for Determination Intracavernosal injection by patient on an as needed basis up to 3 times per week.
J0630	INJECTION, CALCITONIN SALMON, UP TO 400 UNITS	Injection Calcitonin-salmon up to 400 unites, Calcimar®, Miacalcin®	12/01/2002	N/A	Rationale for Determination Subcutaneous injection by patient every day or every other day for a prolonged period of time.
J1324	INJECTION, ENFUVIRTIDE, 1 MG	Enfuvirtide Fuzeon	12/16/2004	N/A	Rationale for Determination Subcutaneous injection frequently for a prolonged period of time.
J1438	INJECTION, ETANERCEPT, 25 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED)	Enbrel®	12/01/2002	N/A	Rationale for Determination Subcutaneous injection twice per week for a prolonged period of time.
J1595	INJECTION, GLATIRAMER ACETATE, 20 MG	Copaxone	09/15/2003	N/A	Rationale for Determination Subcutaneous injection by patient every other day for a prolonged period of time.
J1675	INJECTION, HISTRELIN ACETATE, 10 MICROGRAMS	Supprelin	08/15/2006	N/A	Rationale for Determination Subcutaneous injection daily for a prolonged period of time.
J1815	INJECTION, INSULIN, PER 5 UNITS	Humalog Regular NPH Lente Ultralente	12/01/2002	N/A	Rationale for Determination Subcutaneous injection by patient every day for a prolonged period of time.
J1817	INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS	Humalog Regular NPH Lente Ultralente	12/01/2002	N/A	Rationale for Determination Subcutaneous injection by patient every day for a prolonged period of time.
J1830	INJECTION INTERFERON BETA-1B, 0.25 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED)	Betaseron®	12/01/2002	N/A	Rationale for Determination Subcutaneious injection by patient every other day for a prolonged period of time.
J2354	INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR INTRAVENOUS INJECTION, 25 MCG	Octreotide (short acting subcutaneous dose) Sandostatin	05/01/2003	N/A	Rationale for Determination Subcutaneous injection frequently for a prolonged period of time.
J2940	INJECTION, SOMATREM, 1 MG	Protropin®, Genotropin®, Humatrope®, Norditropin®, Nutropin®, Saizen®, Serostim®	12/01/2002	N/A	Rationale for Determination Subcutaneous injection by patient several times per week for a prolonged period of time.
J2941	INJECTION, SOMATROPIN, 1 MG	Protropin®, Genotropin®, Humatrope®, Norditropin®, Nutropin®, Saizen®, Serostim®	12/01/2002	N/A	Rationale for Determination Subcutaneous injection by patient several times per week for a prolonged period of time.
J3030	INJECTION, SUMATRIPTAN SUCCINATE, 6 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED)	Imitrex®	12/01/2002	N/A	Rationale for Determination Subcutaneous injection by patient at onset of symptoms up to two times in a 24 hour period on an as needed basis.
J3110	INJECTION, TERIPARATIDE, 10 MCG	Teriparatide Forteo	04/15/2003	N/A	Rationale for Determination Subcutaneous injection frequently for a prolonged period of time.
J3355	INJECTION, UROFOLLITROPIN, 75 IU	Bravelle	08/15/2006	N/A	Rationale for Determination Subcutaneous injection daily for a prolonged period of time.
J3490	UNCLASSIFIED DRUGS	Pegylated interferon alfa-2a Pegasys	04/15/2003	N/A	Rationale for Determination Subcutaneous injection frequently for a prolonged period of time.
J3490	UNCLASSIFIED DRUGS	Peginterferon alfa-2b PEG-Intron	05/01/2003	N/A	Rationale for Determination Subcutaneous injection by patient every day for a prolonged period of time.
J3490	UNCLASSIFIED DRUGS	Anakinra Kineret	09/15/2003	N/A	Rationale for Determination Subcutaneous injection by patient every day for a prolonged period of time.
J9212	INJECTION, INTERFERON ALFACON-1, RECOMBINANT, 1 MCG	Infergen	05/01/2003	N/A	Rationale for Determination Subcutaneous injection frequently for a prolonged period of time.
J9216	INTERFERON, GAMMA 1-B, 3 MILLION UNITS	Actimmune	04/15/2003	N/A	Rationale for Determination Subcutaneous injection frequently for a prolonged period of time.
J9218	LEUPROLIDE ACETATE, PER 1 MG	Lupron	12/01/2002	N/A	Rationale for Determination Dose form for daily subcutaneous injection by patient for a prolonged period of time.
J2170	INJECTION, MECASERMIN, 1 MG	IPLEX, Increlex	07/16/2007	N/A	Dose form for more than once daily subcutaneous injection by patient for more than two weeks.
Q0515	INJECTION, SERMORELIN ACETATE, 1 MICROGRAM	sermorelin, Geref	07/16/2007	N/A	Dose form for daily subcutaneous injection by patient for more than two weeks.
J3490	UNCLASSIFIED DRUGS	exenatide, Byetta	07/16/2007	N/A	Dose form for daily subcutaneous injection by patient for more than two weeks.
J3490	UNCLASSIFIED DRUGS	Pramlintide acetate, Symlin®	07/16/2007	N/A	Dose form for daily subcutaneous injection by patient for more than two weeks.
J3590	UNCLASSIFIED BIOLOGICS	Efalizumab, Raptiva	07/16/2007	N/A	Dose form for daily subcutaneous injection by patient for more than two weeks.
J3590	UNCLASSIFIED BIOLOGICS	Pegvisomant, Somavert®	07/16/2007	N/A	Dose form for daily subcutaneous injection by patient for more than two weeks.

Other Information

Other Comments
Not applicable
Revision History Explanation
Article published July 2008: This article replaces - A2372 - Self-Administered Drug Exclusion - Medical Policy Article.

Related Documents
Article(s) A47521 - Process for Determining Self-Administered Drug Exclusions – Medical Policy Article